Functional Electrical Stimulation and Brain-Machine Interfaces for Simultaneous Control of Wrist and Finger Flexion.

Brain-machine interface (BMI) controlled functional electrical stimulation (FES) is a promising treatment to restore hand movements to people with cervical spinal cord injury. Recent intracortical BMIs have shown unprecedented successes in decoding user intentions, however the hand movements restored by FES have largely been limited to predetermined grasps. Restoring dexterous hand movements will require continuous control of many biomechanically linked degrees-of-freedom in the hand, such as wrist and finger flexion, that would form the basis of those movements. Here we investigate the ability to restore simultaneous wrist and finger flexion, which would enable grasping with a controlled hand posture and assist in manipulating objects once grasped. We demonstrate that intramuscular FES can enable monkeys with temporarily paralyzed hands to move their fingers and wrist across a functional range of motion, spanning an average 88.6 degrees at the metacarpophalangeal joint flexion and 71.3 degrees of wrist flexion, and intramuscular FES can control both joints simultaneously in a real-time task. Additionally, we demonstrate a monkey using an intracortical BMI to control the wrist and finger flexion in a virtual hand, both before and after the hand is temporarily paralyzed, even achieving success rates and acquisition times equivalent to able-bodied control with BMI control after temporary paralysis in two sessions. Together, this outlines a method using an artificial brain-to-body interface that could restore continuous wrist and finger movements after spinal cord injury.

Time and Cost Savings of Virtual Established Plastic Surgery Care Using Time-Driven Activity-Based Costing: Lessons from An Academic Clinic.

BACKGROUND: Various surgical subspecialties, including plastic surgery, have begun to embrace virtual clinic visits, especially since the COVID-19 pandemic. However, the impact of video visits on time optimization and cost incurred in outpatient plastic surgery clinics has not been studied. METHODS: Using the time-driven activity-based costing (TDABC) method, we examined the time and cost of in-person and virtual visits at an academic plastic surgery clinic. We formulated process maps for four visit types: physician-led in-person, physician assistant-led in-person, physician-led virtual, and physician assistant-led virtual. The time associated with each visit type was generated by direct observation. The cost associated with each visit type was calculated from representative salary information and estimation of resource costs. RESULTS: Virtual visits took on average less time (25.3 minutes for physician-led visits and 24.4 minutes for physician assistant-led visits), compared to in-person visits (48.2 minutes for physician-led and 41.1 minutes for physician-assistant-led visits) (p<0.001). Virtual visits were also cheaper, at $52.80 for physician-led visits and $20.70 for physician assistant-led visits, compared to in-person visits ($261.13 for physician-led and $236.00 for physician assistant-led visits). Non-provider activities made up the majority of traditional in-person visits (75.7% of the visit for physician-led and 77.6% for physician assistant-led visits), which contributed to higher overall cost of in-person visits for both groups of providers. CONCLUSIONS: Virtual clinic visits can produce time and cost savings without reducing the amount of face-to-face time between providers and patients. Virtual visits can be a useful adjunct to traditional in-person visits.

Financial Toxicity in Breast Reconstruction: The Role of the Surgeon-Patient Cost-of-Care Discussion.

The financial burden of breast cancer treatment and reconstruction is a significant concern for patients. Patient desire for preoperative cost-of-care counseling while navigating the reconstructive process remains unknown. A cross-sectional survey of women from the Love Research Army was conducted. An electronic survey was distributed to women over 18 years of age and at least 1 year after postmastectomy breast reconstruction. Descriptive statistics and multivariable modeling were used to determine desire for and occurrence of cost-of-care discussions, and factors associated with preference for such discussions. Secondary outcomes included the association of financial toxicity with desire for cost discussions. Among 839 women who responded, 620 women (74.1%) did not speak to their plastic surgeon and 480 (57.4%) did not speak to a staff member regarding costs of breast reconstruction. Of the 550 women who reported it would have been helpful to discuss costs, 315 (57.3%) were not engaged in a financial conversation initiated by a health care provider. A greater proportion of women who reported financial toxicity, compared to those who did not, would have preferred to discuss costs with their plastic surgeon (65.2% vs. 43.5%, p < 0.001) or a staff member (75.5% vs. 59.3%, p < 0.001). Among women with financial toxicity, those who had some form of insurance (private, Medicaid, Medicare, "other") were significantly more likely to prefer a cost-of-care discussion ( p < 0.001, p = 0.02, p = 0.05, p = 0.01). Financial discussions about the potential costs of breast reconstruction seldom occurred in this national cohort. Given the reported preference and unmet need for financial discussions by a majority of women, better cost transparency and communication is needed.

Realizing Upper Extremity Bionic Limbs: Leveraging Neuroprosthetic Control Strategies.

SUMMARY: Innovations in the fields of prosthetic devices and neuroprosthetic control strategies have opened new frontiers for the treatment and rehabilitation of individuals undergoing amputation. Commercial prosthetic devices are now available with sophisticated electrical and mechanical components that can closely replicate the functions of the human musculoskeletal system. However, to truly recognize the potential of such prosthetic devices and develop the next generation of bionic limbs, a highly reliable prosthetic device control strategy is required. In the past few years, refined surgical techniques have enabled neuroprosthetic control strategies to record efferent motor and stimulate afferent sensory action potentials from a residual limb with extraordinary specificity, signal quality, and long-term stability. As a result, such control strategies are now capable of facilitating intuitive, real-time, and naturalistic prosthetic experiences for patients with amputations. This article summarizes the current state of upper extremity neuroprosthetic devices and discusses the leading control strategies that are critical to the ongoing advancement of prosthetic development and implementation.

The impact of task context on predicting finger movements in a brain-machine interface.

A key factor in the clinical translation of brain-machine interfaces (BMIs) for restoring hand motor function will be their robustness to changes in a task. With functional electrical stimulation (FES) for example, the patient's own hand will be used to produce a wide range of forces in otherwise similar movements. To investigate the impact of task changes on BMI performance, we trained two rhesus macaques to control a virtual hand with their physical hand while we added springs to each finger group (index or middle-ring-small) or altered their wrist posture. Using simultaneously recorded intracortical neural activity, finger positions, and electromyography, we found that decoders trained in one context did not generalize well to other contexts, leading to significant increases in prediction error, especially for muscle activations. However, with respect to online BMI control of the virtual hand, changing either the decoder training task context or the hand's physical context during online control had little effect on online performance. We explain this dichotomy by showing that the structure of neural population activity remained similar in new contexts, which could allow for fast adjustment online. Additionally, we found that neural activity shifted trajectories proportional to the required muscle activation in new contexts. This shift in neural activity possibly explains biases to off-context kinematic predictions and suggests a feature that could help predict different magnitude muscle activations while producing similar kinematics.

Restoring continuous finger function with temporarily paralyzed nonhuman primates using brain-machine interfaces.

Objective.Brain-machine interfaces (BMIs) have shown promise in extracting upper extremity movement intention from the thoughts of nonhuman primates and people with tetraplegia. Attempts to restore a user's own hand and arm function have employed functional electrical stimulation (FES), but most work has restored discrete grasps. Little is known about how well FES can control continuous finger movements. Here, we use a low-power brain-controlled functional electrical stimulation (BCFES) system to restore continuous volitional control of finger positions to a monkey with a temporarily paralyzed hand.Approach.We delivered a nerve block to the median, radial, and ulnar nerves just proximal to the elbow to simulate finger paralysis, then used a closed-loop BMI to predict finger movements the monkey was attempting to make in two tasks. The BCFES task was one-dimensional in which all fingers moved together, and we used the BMI's predictions to control FES of the monkey's finger muscles. The virtual two-finger task was two-dimensional in which the index finger moved simultaneously and independently from the middle, ring, and small fingers, and we used the BMI's predictions to control movements of virtual fingers, with no FES.Main results.In the BCFES task, the monkey improved his success rate to 83% (1.5 s median acquisition time) when using the BCFES system during temporary paralysis from 8.8% (9.5 s median acquisition time, equal to the trial timeout) when attempting to use his temporarily paralyzed hand. In one monkey performing the virtual two-finger task with no FES, we found BMI performance (task success rate and completion time) could be completely recovered following temporary paralysis by executing recalibrated feedback-intention training one time.Significance.These results suggest that BCFES can restore continuous finger function during temporary paralysis using existing low-power technologies and brain-control may not be the limiting factor in a BCFES neuroprosthesis.

Otolaryngology Program Director, House-Staff, and Student Opinions: Step 1 Pass/Fail Score Reporting.

OBJECTIVE(S): To compare otolaryngology program director, house-staff, and medical student perspectives on the score reporting change of USMLE Step 1 to pass/fail. METHODS: Separate electronic surveys were sent to program directors of ACGME-accredited otolaryngology programs (Cronbach's alpha = .87), otolaryngology house-staff (Cronbach's alpha = .91), and medical students interested in otolaryngology (Cronbach's alpha = .76). RESULTS: Among the 51 otolaryngology program directors that completed the survey (response rate of 46.8%), 17.6% favored reporting USMLE Step 1 as pass/fail. A majority believed the reporting change would make it more difficult to screen (74.5%) and objectively compare applicants (82.4%). Step 2 CK scores will be more important to most program directors due to the reporting change (83.7%). Of the 93 house-staff that completed surveys, most did not favor the reporting change (61.3%). Over half (54.0%) of the 87 medical students that completed surveys did not support the scoring change, and most (65.5%) did not feel that it would decrease anxiety around residency applications (65.5%). Most house-staff and medical students felt that the scoring change would put non-U.S. MD students at a disadvantage (65.6% of house-staff, 69.8% of medical students). CONCLUSION: Most survey respondents do not agree with the decision to report Step 1 as pass/fail. Despite its intended goals, most do not believe pass/fail Step 1 reporting will improve medical student well-being and believe it will put certain student populations at a greater disadvantage.

Ultrasound appearance of regenerative peripheral nerve interface with clinical correlation.

OBJECTIVE: To describe the ultrasound (US) appearance of regenerative peripheral nerve interfaces (RPNIs) in humans, and correlate clinically and with histologic findings from rat RPNI. MATERIALS AND METHODS: Patients (≥ 18 years) who had undergone RPNI surgery within our institution between the dates of 3/2018 and 9/2019 were reviewed. A total of 21 patients (15 male, 6 female, age 21-82 years) with technically adequate US studies of RPNIs were reviewed. Clinical notes were reviewed for the presence of persistent pain after RPNI surgery. Histologic specimens of RPNIs in a rat model from prior studies were compared with the US findings noted in this study. RESULTS: There was a variable appearance to the RPNIs including focal changes involving the distal nerve, nerve-muscle graft junction, and area of the distal sutures. The muscle grafts varied in thickness with accompanying variable echogenic changes. No interval change was noted on follow-up US studies. Diffuse hypoechoic swelling with loss of the fascicular structure of the nerve within the RPNI and focal hypoechoic changes at the nerve-muscle graft junction were associated with clinical outcomes. US findings corresponded to histologic findings in the rat RPNI. CONCLUSION: Ultrasound imaging can demonstrate various morphologic changes involving the nerve, muscle, and interface between these two biological components of RPNIs. These changes correspond to expected degenerative and regenerative processes following nerve resection and muscle reinnervation and should not be misconstrued as pathologic in all cases. N5 and N1 morphologic type changes of the RPNI were found to be associated with symptoms.

Managing Resident Mental Health: Prevention is Better than Cure.

OBJECTIVE: There is a high prevalance of burnout and mental health illness among trainees. Through structured meetings, Program Directors (PDs) have an opportunity to screen and aid residents that may be affected by mental health concerns. However, barriers to this process exist. This study sought to evaluate the perspectives of PDs regarding mental health screening for trainees. DESIGN: A 13-item survey-based study. SETTING: Electronic distribution of the survey was performed via three individualized requests sent via e-mail to PDs. PARTICIPANTS: PDs of 5 ACGME specialties, including Internal Medicine, Pediatrics, Emergency Medicine, General Surgery, and Psychiatry were invited to participate. RESULTS: In total, 595 PDs responded to the survey (response rate = 40.0%) In general, PDs expressed dissatisfaction with the management of burnout and mental health. Most PDs supported periodic screening of residents for burnout (87.0%) and mental health (73.9%). For a resident that could screen positive for mental illness, most PDs were concerned about the possibility of harm to a patient (70.7%) and implications for future licensing (65.7%). Only 30.2% of PDs currently use some form of standardized screening to identify residents struggling with mental health and burnout concerns. CONCLUSION: The majority of PDs across 5 ACGME specialties support the use of periodic screening of residents for burnout and mental health. However, concerns exist regarding such screening such as the implications for future licensing. Additional work needs to be done to address PD concerns and destigmatizate mental health wellbeing and care among trainees.

Resident Mental Health and Burnout: Current Practices and Perspectives of Urology Program Directors.

OBJECTIVE: To understand perspectives of urology program directors (PDs) regarding the management and screening of resident mental health and burnout. METHODS: After piloting and survey validation, an IRB-exempt 14 question survey was distributed to PDs of all 145 ACGME accredited urology residency programs. Statistical significance was determined using an alpha value of 0.05 and response plurality was determined by non-overlapping 95% confidence intervals. RESULTS: A total of 72 PDs completed the survey (response rate = 49.6%). The majority of PDs (59.7%) do not use standardized screening for resident burnout or mental health. A statistically significant proportion of PDs agreed to implementing periodic mental health (75.0%, 95% CI [65.0%-75.0%]) and burnout (87.6%, 95% CI [79.9%-95.1%]) screening. Female PDs were more likely to agree to implementing mental health screening compared to male PDs (female=94.4% vs male=68.5%; P =.03). If mental health screening was implemented and a resident tested positive, PDs were most concerned about harm to a patient (72.2%, 95% CI [61.9-82.6]) and implications of a positive screen on future licensing and practice (55.6%, 95% CI [44.1-67.0]). CONCLUSION: Although the majority of urology PDs believe residents should be periodically screened for burnout and mental health, most do not currently screen their trainees. If mental health screening was implemented, PDs expressed concern about patient harm and challenges associated with future licensing. Our survey results suggest opportunities for improving management of resident burnout and mental health.

Financial Toxicity in Breast Reconstruction: A National Survey of Women Who have Undergone Breast Reconstruction After Mastectomy.

BACKGROUND: Despite awareness regarding financial toxicity in breast cancer care, little is known about the financial strain associated with breast reconstruction. This study aims to describe financial toxicity and identify factors independently associated with financial toxicity for women pursuing post-mastectomy breast reconstruction. METHODS: A 33-item electronic survey was distributed to members of the Love Research Army. Women over 18 years of age and at least 1 year after post-mastectomy breast reconstruction were invited to participate. The primary outcome of interest was self-reported financial toxicity due to breast reconstruction, while secondary outcomes of interest were patient-reported out-of-pocket expenses and impact of financial toxicity on surgical decision making. RESULTS: In total, 922 women were included (mean age 58.6 years, standard deviation 10.3 years); 216 women (23.8%) reported financial toxicity from reconstruction. These women had significantly greater out-of-pocket medical expenses. When compared with women who did not experience financial toxicity, those who did were more likely to have debt due to reconstruction (50.9% vs. 3.2%, p < 0.001). Younger age, lower annual household income, greater out-of-pocket expenses, and a postoperative major complication were independently associated with an increased risk for financial toxicity. If faced with the same decision, women experiencing financial toxicity were more likely to decide against reconstruction (p < 0.001) compared with women not experiencing financial toxicity. CONCLUSIONS: Nearly one in four women experienced financial toxicity from breast reconstruction. Women who reported higher levels of financial toxicity were more likely to change their decisions about surgery. Identified factors predictive of financial toxicity could guide preoperative discussions to inform decision making that mitigates undesired financial decline.

Comprehensive Reform and Greater Equity in Applying to Residency-Trainees' Mixed Responses to a Pass/Fail USMLE Step 1.

BACKGROUND: Pass/fail USMLE Step 1 score reporting may have varying implications for trainees of different demographic and training backgrounds. OBJECTIVE: To characterize the perspectives of a diverse cohort of trainees on the impact of pass/fail Step 1 score reporting. METHODS: In 2020, 197 US and international medical school deans and 822 designated institutional officials were invited to distribute anonymous electronic surveys among their trainees. Separate surveys for medical students and residents/fellows were developed based on the authors' prior work surveying program directors on this topic. Underrepresented in medicine (UiM) was defined in accordance with AAMC definitions. Descriptive and comparative analyses were performed, and results were considered statistically significant with P < .05. RESULTS: A total of 11 633 trainees responded (4379 medical students and 7254 residents/fellows; 3.3% of an estimated 285 000 US trainees). More students favored the score reporting change than residents/fellows (43% vs 31%; P < .001; 95% CI 0-24). Trainees identifying as UiM were more likely to favor the change (50% vs 34%; P < .001; 95% CI 0-32) and to agree it would decrease socioeconomic disparities (44% vs 25%; P < .001; 95% CI 0-38) relative to non-UiM trainees. Nearly twice as many osteopathic and international medical graduate students felt they would be disadvantaged compared to MD students because of pass/fail score reporting (61% vs 31%; P < .001; 95% CI 0-60). CONCLUSIONS: Trainee perspectives regarding USMLE Step 1 score reporting are mixed. UiM trainees were more likely to favor the score reporting change, while osteopathic and international medical students were less in favor of the change.

Real-time linear prediction of simultaneous and independent movements of two finger groups using an intracortical brain-machine interface.

Modern brain-machine interfaces can return function to people with paralysis, but current upper extremity brain-machine interfaces are unable to reproduce control of individuated finger movements. Here, for the first time, we present a real-time, high-speed, linear brain-machine interface in nonhuman primates that utilizes intracortical neural signals to bridge this gap. We created a non-prehensile task that systematically individuates two finger groups, the index finger and the middle-ring-small fingers combined. During online brain control, the ReFIT Kalman filter could predict individuated finger group movements with high performance. Next, training ridge regression decoders with individual movements was sufficient to predict untrained combined movements and vice versa. Finally, we compared the postural and movement tuning of finger-related cortical activity to find that individual cortical units simultaneously encode multiple behavioral dimensions. Our results suggest that linear decoders may be sufficient for brain-machine interfaces to execute high-dimensional tasks with the performance levels required for naturalistic neural prostheses.

Regenerative Peripheral Nerve Interfaces for the Treatment and Prevention of Neuromas and Neuroma Pain.

A neuroma occurs when a regenerating transected peripheral nerve has no distal target to reinnervate. This situation can result in a hypersensitive free nerve ending that causes debilitating pain to affected patients. No techniques to treat symptomatic neuromas have shown consistent results. One novel physiologic solution is the regenerative peripheral nerve interface (RPNI). RPNI consists of a transected peripheral nerve that is implanted into an autologous free skeletal muscle graft. Early clinical studies have shown promising results in the use of RPNIs to treat and prevent symptomatic neuromas. This review article describes the rationale behind the success of RPNIs and its clinical applications.

Regenerative Peripheral Nerve Interfaces for Advanced Control of Upper Extremity Prosthetic Devices.

The quest to find the ideal prosthetic device interface that enables intuitive control has motivated several recent innovations. Although current prosthetic device control strategies have advanced the field of neuroprosthetic control, they are limited in their ability to generate reliable, stable, and specific signals to replicate the complex movements of the upper extremity. The regenerative peripheral nerve interface (RPNI) is a promising solution to enhance prosthetic device control. This article describes the development of RPNIs and summarizes its successful use in the control of advanced prosthetic devices in patients with upper extremity amputations.

An Evidence-Based Guide for Managing Phalangeal Fractures.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe treatment options for phalangeal fractures. 2. Choose an appropriate fracture management plan that optimizes patient goals and range of motion. 3. Describe closed and open reduction techniques of commonly encountered phalangeal fracture patterns. SUMMARY: Phalangeal fractures are the second most common upper extremity fracture. Although many can be treated with splinting, operative intervention may be required for unstable fracture patterns and those involving the articular surface. Failure to appropriately treat these fractures can result in finger stiffness, loss in range of motion, and functional deficits. The type of fixation method can range from percutaneous pinning to open reduction and internal fixation. This article presents a series of cases to illustrate the appropriate management of phalangeal fractures using an evidence-based approach.